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Big changes on tap for state health care exchange

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Some big changes are coming to this year's state health insurance exchange.

The NY State of Health has unveiled a new plan for low-income residents who don't qualify for Medicaid, called the Essential Plan. The state estimates that it will affect about 470,000 New Yorkers, about half of whom would have been otherwise eligible for a health plan on the exchange with a subsidy. The other half would have been eligible for Medicaid or were uninsured.

And the surprise demise of major insurer Health Republic, announced little more than a month before the opening of this year's enrollment, will leave about 80,000 current enrollees -- including more than 16,000 on Long Island -- scrambling to find new insurance. On Long Island, 10 qualified health plans remain. The average increase for the silver plan -- the most popular -- is 5.2 percent.

Enrollment starts soon

Enrollment on the exchange begins Sunday and ends Jan. 31.

The idea behind the Essential Plan is to capture those people who might have decided not to buy health insurance because it was still too expensive even with a federal subsidy or who struggled to pay their monthly premiums and deductibles.

Those who qualify must earn between 139 percent and 200 percent of the federal poverty level -- or no more than $23,540 for a single person and $48,500 for a family of four. It also includes low-income legal immigrants who have been in the United States less than five years and are not eligible for federal Medicaid. Premiums will be between $0 and $20 per adult a month and there are no deductibles.

The state said the plan will cost $2.6 billion for 2016-17, $2 billion of which will be paid for by the federal government.

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"Because federal payments for this program offset traditional state-only costs, it is estimated that New York will save $519 million in 2016-17 as a result of this program," the state health department said in an email. Minnesota is the only other state to offer this coverage, the health department said.

A 'game changer'

Stacy Villagran, in charge of enrollment at the Nassau-Suffolk Hospital Council, designated a "navigator" agency by the state to help sign up people on the exchange, said she believed the new program would be "a game changer."

"Even if people were previously eligible for a qualified health plan, they weren't necessarily enrolled," she said. "A lot of them walked away because it was still too expensive for them."

More people may want to get health insurance this year because the penalties for not having it are rising. In 2015 it was either $325 or 2 percent of income, whichever was higher. But in 2016 it increases to $695 or 2.5 percent of income, whichever is greater.

In Nassau, six insurers will offer the Essential Plan: Affinity, Empire BlueCross BlueShield HealthPlus, Fidelis Care, EmblemHealth, Healthfirst and United Healthcare. In Suffolk, the plan will be offered by all but Empire.

One caveat: Those who qualify for Essential Plan won't be able to keep their current one -- unless they pay the full cost without a subsidy.

And that bothers Jason Samel, president of JayMar Insurance Agency in Jericho, who said at least a quarter of his clients will qualify for an Essential Plan. He said that the network offerings of doctors will be too limited -- a way for insurance companies to keep costs low.

"You're taking people out of plans that they have come to know as their own and throwing them into Medicaid-like plans," he said.

More important, he said, most people don't even know about the new coverage and may assume that they will automatically stay with their current plan.

The health department said those eligible for the Essential Plan are beginning to receive notices from the NY State of Health. If their current insurer offers the Essential Plan, they can be auto-enrolled into the new, cheaper plan, the state said. If not, "the notice will advise them to select a new plan," the state said.

Several insurers offering the Essential Plan said their networks of doctors and other health care providers will be competitive.

New sign-ups expected

"I think this is an opportunity to reach a new population that will be shopping for a plan," said Pamela Hassen, chief marketing officer for Fidelis Care. "The basic coverage is the same. The difference will be in network quality and standards and our reputation."

Jack Stephenson, president of Empire BlueCross BlueShield HealthPlus, said the company was "very excited about the Essential Plan. It's what distinguishes New York as a progressive state."

"There are certainly challenges with network development, but I think we have a robust network," he said.

George Babitsch, senior vice president of EmblemHealth, said its network for the Essential Plan includes about 45,000 providers -- larger than the 28,000 to 30,000 it will offer on the exchange for its qualified health plan.

"We think that's pretty robust," he said.

Babitsch also said signing with Stony Brook University Hospital, the largest hospital in Suffolk, will add about 800 providers to its Suffolk network. The hospital, which had accepted only Health Republic, announced last Tuesday that it had signed with EmblemHealth and was in talks with other insurers.

"We're very excited about signing with Stony Brook," he said. "That rounds out our network very well."

Doesn't work for some

But Karen Valadez of Port Jefferson, a client of Samel's, said EmblemHealth "was not going to work for us."

She said she had been extremely happy with the Health Republic plan for her, her husband and two daughters, ages 9 and 14 -- both because its network coverage included their doctors and because Stony Brook took the insurance.

"That's an essential piece as far as I'm concerned," she said of Stony Brook.

But she said Emblem by comparison was more expensive and included only two providers within 20 miles.

"We'd have to leave our doctors," she said.

Instead, she said she will go with an Oxford plan off the exchange that Stony Brook accepts and that has a larger network. "It's peace of mind really," she said.

Memorial Sloan-Kettering Cancer Center in Manhattan also accepted only Health Republic from the exchange. It is in talks with other insurers, spokeswoman Rebecca Williams said. "In addition, we are working to identify how best to assist MSK patients who are in active treatment and insured by Health Republic," she said.

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